David Hiltz on Resuscitation

In mid-May, FDNY hosted an educational conference on the topic of resuscitation. Numerous invited speakers, including medical directors from many of the country’s largest EMS systems, discussed issues like current research trends, “pit crew” models for CPR, and optimizing systems of care for communities.

I attended with David Hiltz, a longtime paramedic who now works with the AHA. A lot of valuable ideas were shared that weekend, including some material that bears upon Dave’s own work. I asked him to discuss it with me, bringing to bear his perspectives as a field provider, an educator, and a longtime “bridge builder” for Sudden Cardiac Arrest continuity of care.

A disclaimer: David’s participation here is solely personal in nature, and none of his comments or opinions should be understood as being officially endorsed or approved by the American Heart Association.

Brandon Oto: Dave, for those not familiar with you and your work, can you introduce yourself briefly?

David Hiltz: I have been in the healthcare industry since 1984, and over time, working in hospital emergency departments and with EMS agencies, I developed an interest in resuscitation. I have been on staff with the American Heart Association’s Emergency Cardiovascular Care Programs for over 13 years and during that time, I have had the good fortune of meeting some really brilliant and committed people from whom I have learned so much.

BO: You’re involved with the AHA’s HEARTSafe Communities initiative. Can you tell us about that? What are you and the AHA trying to do?

DH: To be correct, the HEARTSafe program does not really “belong” to anyone. Rather, it’s a concept for communities to use in improving recognition, response, care, and outcomes for cardiac arrest patients.

The HEARTSafe program is a population and criteria-based incentive program designed to advance systems change in accordance with the American Heart Association’s Chain of Survival. Individuals, businesses, public officials, and emergency responder agencies are asked to establish a cardiac arrest response system geared toward these criteria.

The primary goal of the HEARTSafe Communities program is to increase survival rates from out-of-hospital cardiac arrest. Individual communities are asked to develop and implement lifesaving strategies that focus on coordinating local resources to prevent sudden cardiac arrest from becoming sudden cardiac death.

Half the men and women with serious coronary artery disease first learn about it in a dramatic way: sudden cardiac arrest.

Outcomes at this point depend on whether the collapse is witnessed, whether the bystanders are trained and willing to perform CPR, and whether the arrest has occurred in a system set up to allow the early arrival of needed resources and the timely execution of evidence-based interventions.

Many have recognized the need to improve community systems of emergency cardiovascular care in order to optimize patient survival. The “Chain of Survival” represents the current approach to improving recognition, response, and care.

Decades after its creation, this same systematic and coordinated approach remains the strongest recommendation the resuscitation community can make to save more people in out-of-hospital cardiac arrest. (Not that I have any business being a “representative of the collective opinion” of the resuscitation community!) The idea is simply to maximize each community’s resources by implementing appropriate measures and strategies to achieve the greatest attainable patient survival.

There are numerous systems around the world where the implementation of community-based measures has lead to improved outcomes for critical out-of-hospital patients. I believe that programs such as Heart Rescue and HEARTSafe Communities are valuable frameworks for any group looking to explore related strategies for improving survival and quality of life.

BO: This past May, you and I were able to attend a conference on Randall’s Island, hosted by FDNY and focusing on topics surrounding resuscitation. The main theme was a continuing reinforcement of the basic fundamentals of resuscitation by laypeople and BLS responders, especially the importance of early, ongoing, and high-quality CPR.

Several speakers made the particular point that improving bystander CPR rates is one of the most important and highest-value steps we can take to improve our survival rates; Dr. Chris Colwell described it as the low-hanging fruit of the Chain of Survival. Overall, Dr. Paul Hinchey suggested that we need to shift our priorities away from the clinical practices of professional rescuers and clinical centers, and towards the recruitment of the general population.

Based on your experience with HEARTSafe, what are the principal challenges to improving bystander CPR rates? Why haven’t we been able to accomplish this important and seemingly simple task in all of our communities?

DH: Let me first say how much I enjoyed attending the conference and spending time with old and new friends there.

Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act.

Bystander CPR can dramatically improve survival from cardiac arrest, yet far less than half of victims receive this potentially lifesaving therapy. CPR is inexpensive, readily available, and can save lives. Based on what we know, increasing the rates of bystander-initiated CPR is critical to improving outcomes.

There are a number of theories regarding the hesitation of bystanders to perform CPR, even when adequately trained. Mouth-to-mouth breathing and concern about the transmission of infectious disease may explain reluctance among some. Another potential barrier to learning and performing bystander CPR has been the complexity of past resuscitation guidelines. This complexity may affect a citizen’s willingness to learn CPR skills, contribute to a failure of recall, or negatively impact confidence in their ability to perform during an emergency.

While “fear of failure” is often cited as a major barrier, some bystanders may also decline to perform CPR because of legal concerns, and are often not aware of their protections under Good Samaritan statutes. Many educators and clinicians continue to hear concerns such as, “What if I break a rib?”, “What if the person dies?”, and “Can’t I hurt someone with CPR?” Fears like these should not get in the way of helping another person in their ultimate time of need. Knowing and performing CPR should be thought of as a moral obligation and civic duty.

Widespread access to CPR education is another potential barrier. In many cases, citizens need to make a concerted effort to identify and enroll in a CPR program. For instance, many sources for CPR education focus their efforts on training healthcare providers and do not routinely offer appropriate courses for the general population. This should change.

The marketing surrounding CPR are also important. My experience has been that despite our best intentions, CPR “advertisements” are often poorly conceived and send the wrong message. Make no mistake, regardless of whether you are a hospital, an EMS agency, or a lone instructor, you are marketing and promoting CPR education. If your “message” is not effective, people will not be interested. Consider the following commonly seen messages promoting CPR. Which do you think would be most effective in enlisting the public?

One quarter of Americans say they’ve been in a situation where someone needed CPR. If you were one of them, would you know what to do?

Is learning CPR important? Just ask these people… she learned and he lived

There are 300,000 cases of cardiac arrest each year with 80% occurring in and around the home. Only 5% survive. Learn CPR.

The time to learn CPR was yesterday… tomorrow could be too late.

I highly recommend reading the book Made to Stick, by Chip and Dan Heath. We all want our ideas to be understood, remembered, and have a lasting impact; this book may help you to make your ideas more effective. They also discuss the concept of “The Curse of Knowledge,” which is described as “knowing something too well, so that this knowledge actually inhibits our ability to communicate the essence of it to the audience.” This curse of knowledge can be seen in how we promote CPR to the public as well as in how we often deliver it! I believe that the “curse of knowledge” is a villainous and self-defeating phenomenon that often shows up in our CPR training.

All of us in public safety should remain focused on broadening CPR education for the general public, and there are a number of new programs to help support this, such as the AHA’s “CPR Anytime for Family and Friends” kit and the advent of Hands Only CPR. The CPR Anytime kit makes it possible to deliver hands-on training to large groups of people in a matter of 20-30 minutes. I am particularly supportive of this system, due to studies that demonstrated the effectiveness of the kit being as good as the traditional three- to four-hour courses — 93% of trainees could still perform adequate chest compressions and successfully use an AED six months after learning it.

BO: It sounds like the answers to many of the current problems in addressing Sudden Cardiac Arrest are not medical in nature, but psychological. We’re moving away from questions like “what’s the ideal antiarrhythmic?” and towards questions like “how can we market CPR so people will learn it, teach it so they’ll remember it, and contextualize it so they’ll be willing to do it?”

The reason this shift is both possible and necessary is that there’s a tentative agreement in the literature that, to put it briefly, what works is the simple stuff. As Dr. Chris Colwell laid it out, when it comes to the good old ABCs, compressions are definitely important in arrest — but Airway and Breathing perhaps not so much, and the jury’s still out on exactly what role they should play. But we do know that early, consistent, deep chest compressions, at an appropriate rate, with minimal interruptions do make a difference, and it’s fortunate that this dovetails well with the “human interface” problem, where people have been telling us that bystander CPR was too complicated and scary. So the main goal now is to see how many people we can tag with this meme of “when someone looks dead, push on their chest” — and simpler memes work better.

But what about the role of EMS in this picture? On the one hand, we are trained professionals who have less room to complain about “scary complexity” in our care. On the other hand, we’re human beings too, and we seem to face some of the same problems as laymen — for instance, we bag too fast, we don’t push deep enough, and (as Dr. Paul Hinchey described) we have a nasty habit of interrupting our compressions for all sorts of reasons. Some people were predicting the 2010 AHA Guidelines would see a wholesale switch to compressions-only, even for healthcare providers. That didn’t happen, but is that the general direction we should be going? The clinical picture here isn’t clear — the literature has some support for minimally-interrupted compressions by EMS, but it seems unwise to start demanding that the BVM always stays in the cabinet when there’s no pulse. Respiratory etiologies of arrest — like drowning — make this clear enough. Still, as Dr. Paul Pepe said, would we rather have more oxygenated blood circulating less, or less oxygenated blood circulating more (with fewer interruptions to compressions to allow for breaths)? How far do you think we should take this trend of simplification in the professional setting? Does the “human element” mean that we need to cut things down on the professional side as well?

DH: I think that categorizing citizen CPR “issues” as psychological, psycho-social or as one of behavioral change is correct.

Existing education research suggests that attitudes and behaviors are different from cognitive knowledge and skills, and cannot be adequately addressed through discussion that is simply added or dropped into courses. Perhaps future course design could better address these emotional perceptions. Ideally, the average citizen should want to know how to perform CPR and should feel comfortable about the idea of doing it in a real emergency, perhaps even before they ever give serious consideration to learning the skill itself. Increasing the number of people who are trained and willing to act is essential to improving the likelihood of survival.

EMS providers should be doing whatever is necessary to improve the quality of the resuscitation we provide. This will not be accomplished through initial training and education alone. Examining and optimizing our actual performance in the field is needed: improving resuscitation quality will require regular practice, real-world data collection, and an iterative process of measuring and improving.

Adding more sophisticated gadgets and more complex therapies may not yield the desired results, particularly if the fundamental problems have not been addressed. This would support the general idea of simplification — but because of the diversity among EMS providers and agencies, it is difficult to make any broad statements. Before adding “something else,” it may make sense to first ensure that we are doing the essentials well and consistently.

In addition to improving the quality of our own resuscitation, we as providers also have a unique opportunity to play a role in citizen CPR education. I would even suggest that other public safety agencies, such as fire and police, share this responsibility as well. If we truly believe that EMS is where public health and public safety intersect, then we should be making citizen engagement one of our priorities. There are a wide variety of “off the shelf” programs, products, and strategies that we can put into practice at the local level. Concepts like HEARTSafe Communities, HeartRescue, and other similar models for improving community response to cardiac arrest can provide guidance for implementation.

Desire and intellectualization alone are not enough to save lives. Full implementation of the AHA recommendations will improve outcomes, but it requires the involvement of each provider, agency, and system to make resuscitation quality a priority and lead the effort to save lives.

BO: Paul Hinchey talked about CPR devices and adjuncts like the LUCAS and the Zoll AutoPulse. The current evidence seems to indicate that these devices are no more effective at increasing survival to discharge than perfect-quality manual CPR. However, when perfect-quality manual CPR is not possible, a mechanical device may have a role. In particular, Dr. Hinchey pointed out that if we begin to routinely accept codes directly into the cath lab for intra-arrest PCI, then transports prior to ROSC would become a valuable option in some situations, and due to the challenges of continuing CPR while packaging and transporting, mechanical devices might then come into their own.

This idea seems to mirror another idea involving “code drugs” like epinephrine and amiodarone. Currently there is no evidence that any of these drugs improve survival to hospital discharge — the only outcome that really matters. However, they may improve survival to hospital admission, and one argument for their continued use is that if we can keep people “alive” (neurologically intact and with a salvagable myocardium) until they get into the hospital, then perhaps later advanced care (such as catheterization, ECMO, therapeutic hypothermia, or other future remedies) might be able to get them back out again. In such cases, even an intervention that only supports part of the Chain of Survival might have ultimate value if something else can provide the last few links.

In any case, do you believe devices that “replace” the rescuer in providing the major components of CPR can have a role? Assume that, as have tentatively found, they do the job no better than an ideal human, but also no worse. With all the challenges we’re encountering in getting really consistent performance from our rescuers, are there some situations where we should simply cut our losses and turn the job over to a machine? Obviously this won’t always be possible — unless every citizen carries their own Thumper — but we could move towards a point where every EMS and first response unit carried such a device and made attaching it a priority.

DH: A variety of devices have been developed and promoted in an effort to enhance perfusion during cardiac arrest. Generally speaking, these devices require more personnel, training, and equipment, or apply only to specific settings. Although the idea of using technology to improve perfusion during arrest is indeed intriguing, I think it is important to remember that the application and use of these devices also has a potential to delay or interrupt CPR. Since we do know that delays and interruptions negatively impact survival, agencies and rescuers choosing to use these devices need to be acutely aware of this downside, and take steps (such as appropriate training) to minimize potential interruptions in chest compressions and/or defibrillation.

To quote the current AHA-ECC and CPR Guidelines: “To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.” Also, “Class IIb recommendations are identified by terms such as “can be considered” or “may be useful” or “usefulness/effectiveness is unknown or unclear or not well established.”

High-quality CPR is fundamental to the success of any “ACLS” type of intervention. We should place the highest priority on performing good chest compressions with adequate rate, depth and complete recoil. Interruptions in chest compressions and unintentional hyperventilation must be avoided. In particular, for patients with shockable rhythms, defibrillation should be delivered with minimal interruption in chest compressions.

To date, increased rates of ROSC associated with ACLS drug therapy have not translated into long-term survival benefit… but perhaps improved quality of CPR, combined with advances in post-resuscitation care, will provide additional insight regarding the role of drugs in optimizing outcomes.

I think it is also appropriate to consider the process of organ and tissue procurement in an effort to minimize waiting time and alleviate suffering for patients qualifying for organ transplant. In my opinion, there is room to improve efforts relating to the ethical procurement of organ and tissue donations.

Based on what I know, and in my opinion, mechanical devices can’t replace a rescuer in providing the major components of CPR. They may have a role in certain circumstances and settings, but there is a clear and continued need for human hands on the chest. Adding a mechanical device will not, by itself, solve CPR quality issues. Additionally, without careful implementation, these devices could potentially hinder rather than help the CPR process. Incorporating them is fine and could be very appropriate in certain settings, but caution and careful implementation is needed.

BO: Thanks for bringing that up; we often don’t think about CPR’s role in maintaining viable organs and tissue for transplant.

You mentioned post-resuscitation care. One of the points Dr. John Freese made is that, when it comes to practical implementation of post-ROSC therapeutic hypothermia protocols, we’ve found that starting hypothermia prior to ED arrival can be beneficial. This isn’t necessarily for clinical reasons, but instead because hypothermic therapy already initiated when the patient arrives at the hospital is very likely to be continued in the hospital — whereas if it is not yet initiated, the patient may or may not end up being cooled, depending on how aggressively and consistently that facility is applying a hypothermia protocol. In other words, field treatment in this case is playing an economic or policy role, by letting the EMS side say to the hospital side: “We’ve already started this beneficial therapy — you’re not going to terminate it, are you?” And in fact, if they’re still reluctant to get on board, it becomes reasonable for us to divert these patients to other facilities instead, applying further economic pressure.

This is an example of a change in the standard of care being pushed through by a “grassroots” type of influence, as opposed to a top-down fiat which may take much longer to occur (due to institutional inertia or financial concerns). Many of our readers may have experienced frustration with the slow pace of change in their own systems. You’ve done a lot of work with implementing large-scale adoption of new training and procedures in different communities; in your experience, what’s the best way to approach this? Is it top-down, by seeking buy-in from administrators and medical directors at the highest level, or is it from the trenches, by finding broad support for the initiative from clinical staff or even from the public?

DH: An interesting perspective and suggestion, Brandon. I think you did an excellent job of framing up the subject. Improving systems of care for stroke, STEMI, and cardiac arrest patients can be very complex, to say the least. Increasingly I am finding that EMS can play an essential role in developing an integrated systems approach to optimizing response, care, and outcomes.

Yes, Dr. Freese made a compelling suggestion concerning the implementation of EMS therapeutic hypothermia protocols, and his point about continuity of hypothermic therapy is one that I have also observed. This is a great example of a practice being “imported” from the out-of-hospital environment to the hospital setting.

It is difficult if not impossible to make a single recommendation that will hold true everywhere. However, EMS providers, leaders, and agencies will be integral components of any localized strategies of care.

Multi-party coalitions involving EMS field providers, representatives from local prehospital and hospital agencies, and emergency physicians as well as cardiologists can help coordinate strategies for improving cardiac arrest outcomes within a region. This can involve not only therapeutic hypothermia, but the entire spectrum of issues associated with a comprehensive system of care for these patients.

In order to effectively address the issues, such coalitions need a thorough and honest understanding of what is working and what is not. This requires an examination of all system components and how they interact. Each member’s input can help in defining and framing the overall issues, as well as in the development of strategies to yield life-saving results.

Unless a system is hopelessly obstinate, changing and improving standards of care through a combination of “grassroots” influence as well as a top-down approach may yield the most desirable results. Indeed, in my experience, this has been the most effective means of implementing change. Programs like Mission: Lifeline, HEARTSafe, and Heart Rescue can also offer good frameworks for developing this type of process.

BO: Dave, it’s been a pleasure; I hope we can chat again soon. One of the best things the internet has done for EMS is to bring together widespread people with different ideas from different places, but with many of the same problems. My thanks to FDNY for hosting a great (and affordable!) conference, and to yourself for taking some time to discuss it.

Any parting words?

DH: The pleasure has been all mine!

Additional remarks:

An agency or system’s ability to resuscitate VF cardiac arrest can be an excellent indicator of its overall clinical quality.

There is no single change that will dramatically improve cardiac arrest survival. A combination of approaches, including improved recognition, willingness of citizens to perform CPR, telephone CPR (via EMD), rapid defibrillation strategies, really good BLS, and effective post-resuscitation care are all needed to truly move the “survival needle.”

Data collection and an iterative process of measurement and improvement is important in every system.

Desire alone is not enough to yield results. Real effort is required to improve recognition and response. Public safety agencies, EMS included, are well positioned to take the lead in this drive for improvement.

Increased probability of citizen CPR, implementation of AHA guideline recommendations, and improved quality of resuscitation from all rescuers is what is needed in order to save lives.

Comments

I can’t agree more with the statement that more bystanders willing and able to do CPR is a great resource. Recently in a small town near where I am, a man suffered cardiac arrest in front of the grocery store. Several bystanders jumped into action and performed CPR. The local first responders brought him to the fire hall and continued care with an AED now involved. After 96 mins of CPR, shocks and some drugs, he regained a pulse. He was transported to the hospital by helicopter and made a full recovery. A few months later he was able to return to the scene and thank all of the individuals involved. Without the bystander intervention he may have had brain damage or not made it at all. I am looking to get certified to teach CPR so more people in my area could do this as well. It really is a great thing to have people willing to help before EMS arrives.